Mad, bad, or disordered personality?

This book is a tremendous outing for that enfant terrible of psychiatry, personality disorder. Jonathan Dowson and Adrian Grounds, psychiatrists both, marshal a remarkable variety of facts and figures about this neglected topic. Far from being a dustbin diagnosis for the difficult and delinquent, they say, much is known about the incidence and clinical features, the causes and management of these distressing mental disorders. The schizoid (lonely), the paranoid (suspicious), the sociopathic (dangerous), the obsessive (perfectionist), the depressive (sad), and many more, are categorised and coded in this wide-ranging review.

The important subtext of the book is treatability. The medical line has always been that personality disorders are, like personality itself, highly resistant to change. Brain-washing, perhaps, or religious conversion, may alter your life. But in the ordinary run of medical interventions, damage limitation, by changing the environment not the patient, is all that medicine can hope to achieve.

Modern treatments, argue Dowson and Grounds, are changing all that. New behavioural and cognitive psychotherapies, more powerful drugs, including the modern generation of selective antidepressants, such as Prozac, and better targeted neurosurgical procedures, are all showing promise. Out with therapeutic nihilism, then, and in with cautious therapeutic optimism. Caution remains the watchword, though. There may be an occasional therapeutic breakthrough; more often positive responses are modest; and relapse or outright failure are still the most likely outcomes.

All the same, personality disorders can no longer be simply written off as untreatable. And with advances in genetics, neuroscience and psychology, the scope for really effective treatments is likely to be dramatically expanded in the not-too-distant future.

There is a good deal that is encouraging here. As resources shrink, as league tables and performance statistics proliferate, as responsibilities are piled on responsibilities, so care becomes conditional on the possibility of cure. In this economy, the elderly are no asset, the long-term mentally ill are not value for money. But with personality disorder, it now seems, there is a still faint, but quite definite and possibly growing chink of therapeutic coin. With personality disorder, as Dowson and Grounds minutely document, something really can, increasingly, be done.

But should it be done? Dowson and Grounds have little to say about this. In stark contrast to the thoroughness of their review of the empirical issues, the ethical and conceptual problems raised by personality disorders are left not only unexplored but largely unstated.

How far should treatment go? How dangerous must the sociopath be before enforced treatment is justified in the interests of society? Should the schizoid be brought in for treatment in their own interests? Where does treatment end and punishment begin? Where does treatment end and performance enhancement begin? We disapprove of steroids for athletes; but what about Prozac before a vital business meeting or an exam? Such issues turn, in part, on values. But whose values? The patient's? Society's? The GP's? The Department of Health's? They also turn on the trickier question of where to place the personality disorders between disease and delinquency. Are we responsible for our bad characters? Is it all in the genes? Can we take credit for our good characters? Personality disorder is on the very cusp between medicine and morals.

Such issues are not new. Mad or bad? has been an issue, for judges and politicians, for philosophers and doctors, since antiquity. Mad and bad goes back to the French reformer and psychiatrist, Philippe Pinel, working in post-Revolutionary France. Pinel's notion of manie sans delire was introduced into English by the Victorian psychiatrist, James Prichard, as "moral insanity".

What is new, however, and what gives a wholly new urgency to these issues, is Dowson and Grounds's subtext, treatability. The insensitivity to treatment of the personality disorders has in the past been used to justify both neglect by doctors and attributions of responsibility by judges and politicians (Nancy Reagan's "just say no"). Against such attitudes we now have Dowson and Grounds's up-beat message that really effective treatments are on the cards. So far so good. But with this comes a whole raft of dangerous possibilities. Really effective treatment of personality disorders means really effective political control of dissidents; it means really effective suppression of disorder; it means an open cheque for health-care budgets; it means, on the Nancy Reagan view, the end of freedom and responsibility.

Dowson and Grounds make clear that they are not unaware of these dangers. The book opens with a discussion of the problem of definition, of how a properly medical notion of personality disorder should be marked out. But this is dealt with superficially.

There is a strong sense of cutting through to the serious scientific questions, a brisk impatience of the busy clinician, a plain man's acceptance of plainly unsatisfactory definitions "for practical purposes".

The remit of the book is empirical. Ethical and conceptual issues, important as they are, thus rightly take second place. A further volume would be needed to do justice to the relevant literature in areas as diverse as philosophy, jurisprudence, psychology, anthropology and social science. But if, as Dowson and Grounds claim, really effective treatments are coming on stream, then to neglect this literature, to rely uncritically on a narrowly medical model, is likely to become increasingly dangerous precisely for the "practical purposes" to which they are committed.

What does the medical model have to say about Hitler, for example, or indeed about Jesus? Hitler certainly showed, in the words of the American classification of mental disorders (the Diagnostical Statistical Manual) "an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment".

Well, perhaps Hitler was mad not bad; and perhaps the world would have been better off if he had been treated with Prozac. But Jesus fits the definition just as well. The DSM seeks to avoid the embarrassment of such political and religious assimilations by specifying that the "distress or impairment" in question must be "clinically significant", a phrase that is also adopted by Dowson and Grounds. But far from resolving the problem, this merely gives all power to the doctors. For what is to count as clinically significant is left undefined by DSM other than to say that it is a matter for clinical judgement.

Mad or good, then, is as much at issue in DSM as mad or bad. The medical model threatens equally the best with the worst, the genius with the depraved and the merely dotty. And why, come to think of it, if we have a depressive personality disorder, do we not have a happiness personality disorder? If we have a category for the sociopath, with too little moral sense, why not a category for those with too much? Why not a category of moralising-personality-disorder? Or intrusive- journalism-personality-disorder? Or courage-in-the-face-of-adversity personality disorder?

Such questions were of mainly theoretical interest so long as human rights were quarantined by a lack of effective treatments. But if Dowson and Grounds are right the quarantine barrier is about to come down. It is, we must hope, just a coincidence that, at just this time, the home secretary is promoting a new "hybrid order" which would allow a convicted person to be sent from prison to hospital for a trial of treatment. Trial by treatment, I call it.

Bill Fulford is professor of philosophy and mental health, University of Warwick.